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Copy of Maxs Keeping Pets Safe_COVID19 (1).jpg

CLIENT APPLICATION FOR SUPPORT

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Chestnut Crisis Fund Program Eligibility

Pet owners must provide ONLY ONE of these options in order to receive support

  • Letter from employer noting reduction or elimination of work due to COVID 19 
  • Submission of two consecutive pay stubs - one prior to March 13
  • Copy of your application for Unemployment or government support
  • Proof of employment prior to March 13 at business known publicly to have reduced hours or closure
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PET OWNER & SPOUSE/PARTNER/PET CO-OWNER INFORMATION

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First Name
Last Name
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You must submit either through form or by sending photo of your ID/DL to admin@maxshelpingpaws.org

First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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PET INFORMATION

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(If you do not have a regular veterinarian, explain why not here)
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HOUSEHOLD FINANCIAL INFORMATION

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You must submit results from Care Credit Application in order to be considered
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HOUSEHOLD FINANCIAL INFORMATION





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(see accepted options noted in application)

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Please note we are not pay the entire cost of treatment. As a pet owner you are expected to incur some costs for the care of your pet.

Friends, family members, other non profits

I UNDERSTAND AND AGREE THAT:

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I accept and approve the above. If I receive assistance, I consent to use of my pet’s name, image & story by MHPF for website, PR, and other marketing purposes, AND I will cooperate with MHPF to schedule photos, interviews or video as necessary for their use.

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